Knowledge Base — Coding

ICD-10-CM Official Guidelines for Coding and Reporting for FY 2018

Published on Aug 28, 2017

20170828

It’s hard to believe that school is back in session and fall is just around the corner. Here in the Deep South, fans celebrate the return of high school football on Friday night and SEC football on Saturday. Whether you are on a team or a supportive spectator, to truly enjoy the game, you need to have an understanding of the game rules.

This is also the time of year when the IPPS Final Rule and ICD-10-CM Official Guidelines for Coding and Reporting are released for the coming Fiscal Year (FY). For Professional Coders and CDI Specialists, to accurately reflect the severity of illness and resource consumption for your patient population, you need to have an understanding of the changes. This week we focus on highlights from the FY 2018 ICD-10-CM Official Guidelines for Coding and Reporting.

NARRATIVE Changes

Narrative changes within the Guidelines appear in bold text.

“With”

“The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.

In the 2017 Guidelines update, guidance was changed to include that “The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular list. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. New in 2018 this guidance goes on to include the following: “or when another guidelines exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”). For conditions not specifically linked by these relational terms in the classification, or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.”

“Code also” note

“A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.”

Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer-Stages, Coma Scale, and NIH Stroke Scale

Prior to ICD-10 there was no way to capture the National Institutes of Health Stroke Scale (NIHSS). Coding the NIHSS was first included in this section of the Guidelines in 2017 and instructed that coders may code this “based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient… codes should only be reported as secondary diagnoses.”

In the FY 2018 IPPS Final Rule, CMS finalized the proposal to refine the Stroke 30-Day Mortality Rate Measure for the FY 2023 payment determination by including the National Institutes of Health (NIH) Stroke Scale.

Key Takeaway’s for Hospitals

CMS “proposed this measure now to inform hospitals that they should begin to include the NIH stroke severity scale codes in the claims they submit for patients with a discharge diagnosis of ischemic stroke.”

You will need to work with your Physicians to ensure that they are measuring and recording stroke severity.
Coders will need to include the appropriate ICD-10 code from the Physician’s documented NIH Stroke Scale score.
CMS clarified in the FY 2018 IPPS Final Rule that “The intent of the risk adjustment for stroke severity is to account for patients’ clinical status at the time they are admitted to the hospital. Therefore, the refined Stroke 30-Day Morality Rate measure would utilize only the initial NIH Stroke Scale score, which is administered upon admission.”
Advice on the subcategory to report the NIH Stroke Scale scores can be found in Coding Clinic 2016, 4th Quarter, page 61.

In addition to narrative changes, it is essential for the Professional Coder and/or CDI Specialist to pay close attention to when there is guidance to query the provider. The following table details when a query is advised.

When to Query the Provider
Guidelines Section	Query Opportunity
Excludes 1	“An exception to the Excludes 1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes 1 note are related or not, query the provider.”
Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale	“Code assignment may be based on medical record documentation from clinicians who are not the patient’s provider…since this information is typically documented by other clinicians involved in the care of the patient…However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.”
Documentation of Complications of Care	“There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.”
Borderline Diagnosis	“Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification.”
Coding of Sepsis “Negative or Inconclusive blood cultures and sepsis”	“Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition; however, the provider should be queried.”
“Urosepsis”	“The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis…should a provider use this term, he/she must be queried for clarification.”
Acute Organ Dysfunction that is not clearly associated with sepsis	“If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.”
Severe Sepsis	“The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis…due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes.”
Sequencing of Severe Sepsis	“Severe sepsis may be present on admission, but the diagnosis may not be confirmed until sometime after admission. If the documentation is not clear whether severe sepsis was present on admission, the provider should be queried.”
Malignancy in two or more noncontiguous sites	“A patient may have more than one malignant tumor in the same organ…should the documentation be unclear, the provider should be queried as to the status of each tumor so that the correct codes can be assigned.”
Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms in remission versus personal history	There are codes indicating whether or not these conditions have achieved remission. “If the documentation is unclear as to whether the leukemia has achieved remission, the provider should be queried.”
Sequencing of Acute Respiratory Failure and Another Acute Condition	“If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.”
Ventilator Associated Pneumonia	“If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.”
Patients Admitted with Pressure Ulcers Documented as Healed	“Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record…If the current documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.”
Non-Pressure Chronic Ulcers	“Non-pressure ulcers described as healing should be assigned the appropriate non-pressure ulcer code based on the documentation in the medical record…if the documentation is unclear as to whether the patient has a current (new) non-pressure ulcer or if the patient is being treated for a healing non-pressure ulcer, query the provider.”
Acute Traumatic versus Chronic or Recurrent Musculoskeletal Conditions	“Many musculoskeletal conditions are a result of previous injury or trauma to a site, or are recurrent conditions…If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider.”
Chronic Kidney Disease and Kidney Transplant Status	“Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication…If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.”
SIRS due to Non-Infectious Process	“If acute organ dysfunction is documented, but it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition (e.g., directly due to the trauma), the provider should be queried.”
Kidney Transplant Complications	“If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.”
Present on Admission (POA)Reporting Guidelines	“These guidelines are not a substitute for the provider’s clinical judgment as to the determination of whether a condition was/was not present on admission. The provider should be queried regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of findings.”
Timeframe for POA Identification and Documentation	“In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period of time after admission. In some cases it may be several days before the provider arrives at a definitive diagnosis. This does not mean that the condition was not present on admission…If at the time of code assignment the documentation is unclear as to whether a condition was present on admission or not, it is appropriate to query the provider for clarification.”
Assigning the POA Indication	“U” for unknown is assigned “when the medical record documentation is unclear as to whether the condition was present on admission. “U” should not routinely be assigned and used only in very limited circumstances. Coders are encourages to query the providers when the documentation is unclear.”
Source: ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 (October 1, 2017 – September 30, 2018) at https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf

This article provides an overview, be aware that there are several additions to the Chapter-Specific Coding Guidelines (i.e., patient admission/encounter for the insertion of implantation of radioactive elements, diabetes mellitus, blindness, pulmonary hypertension, acute myocardial infarction (AMI) and non-pressure chronic ulcers). Reading the Guidelines is a must for Coding and CDI Professionals as you prepare for the rule changes to the “game” with the start of the 2018 IPPS Fiscal Year on October 1.

Beth Cobb

August Medicare Transmittals and Other Updates

Published on Aug 28, 2017

20170828

| Recovery Auditor

| Billing

| Coding

| Medicare Coverage

| Outpatient Services

For over a year now, MMP has included updates to CMS transmittals and other CMS news related to acute-care hospitals as a standing article in our Wednesday@One newsletter. Do your eyes sometimes glaze over as you scan titles, numbers, dates, links, etc. or do you hear the adult-speak from the Peanuts cartoons (warnk, warnk, warnk)? I know I do, so beginning this month, we are presenting this information in a different format. We will present a single straight-forward short description of the topic of the transmittal or other update. Then if you want to know more, we provide the link to the MLN Article or other applicable document. We hope you find this new format easier to read and a better direction on what you need to know. We welcome your feed-back on our new format.

Updated Part B Drug Pricing Files

Quarterly updates to the ASP Medicare Part B Drug Pricing files.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10187.pdf

New Waived Tests

New waived laboratory tests approved by the FDA for performance in a waived laboratory.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10198.pdf

NPI for CWF Provider Queries

Beginning January 2018, the CWF Provider Queries will only accept NPIs as Valid Provider Numbers.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10098.pdf

Correction to Transfer Payment for MS-DRG 385

CMS is correcting the FISS IPPS Pricer for correct calculation of transfer payments for DRB 385.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10145.pdf

2018 ICD-10-CM POA Exempt Codes Available

The 2018 ICD-10-CM Present on Admission (POA) Exempt Codes are posted on the 2018 ICD-10-CM and GEMs webpage.

Updated Editing of Always Therapy Services

Revised editing of “always therapy” services to require the appropriate therapy modifier in order for the service to be accurately applied to the therapy cap.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10176.pdf

NCD 20.8.4 for Leadless Pacemakers

Effective January 1, 2018, Medicare will cover leadless pacemakers when provided in a CMS-approved study.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10117.pdf

Provider-Based Determination

Beginning November 6, 2017, MACs are required to use a uniform electronic Provider-Based (PB) checklist to perform uniform reviews of provider-based applications.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10095.pdf

HCPCS Codes Used for SNF CB Enforcement

Quarterly (October 1, 2017) update to the list of HCPCS codes that are subject to the Consolidated Billing provision of the SNF Prospective Payment System.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10163.pdf

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Fiscal Year (FY) 2018

Updates to the Medicare Claims Processing Manual based on the IPF PPS final rule for FY 2018 (October 1, 2017 – September 30, 2018)

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10214.pdf

Quarterly Influenza Virus Vaccine Code Update – January 2018

Quarterly update to flu vaccine codes. Effective January 2018, there is one new influenza virus vaccine code: 90756

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10196.pdf

ICD-10 Coding Revisions to National Coverage Determinations (NCDs)

Periodic updates of claim processing edits based on ICD-10 coding for NCDs. Watch these carefully as they may affect which ICD-10 codes support medical necessity for the involved services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10184.pdf

ICD-10 GEMS for 2018 Available

The 2018 General Equivalence Mappings (GEMs) are available:

Diagnosis: 2018 ICD-10-CM and GEMs webpage
Procedures: 2018 ICD-10-PCS and GEMs webpage

This is the last year that the GEMs will be produced. The 2018 ICD-10-CM Guidelines and Conversion Table will be posted once the Centers for Disease Control and Prevention finalizes them.

Inpatient Prospective Payment System (IPPS) Final Rule

The IPPS final rule was published in the Federal Register on Monday, August 14, 2017. The rule finalizes 2018 payment and policy updates for Medicare hospital admissions.

https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf

ICD-10-CM Official Guidelines for Coding and Reporting

National Center for Health Statistics (NCHS) published new coding and reporting guidelines for using ICD-10 for fiscal year 2018.

https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf

Credentials of Reviewers

This transmittal instructs Medicare reviewers (MACs, CERT, RACs, and ZPICs) to ensure complex reviews for coverage determinations are performed by Registered Nurses (RNs), therapists or physicians.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R737PI.pdf

Medicare Parts A & B Appeals Process Booklet

A new MLN booklet (June 2017) describes the appeals process, including the latest changes to the appeals process.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareAppealsProcess.pdf

Influenza Vaccine Payment Allowances - Annual Update for 2017-2018 Season

Provides the Medicare Part B payment allowances for influenza vaccines for August 1, 2017-July 31, 2018.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10224.pdf

Claim Status Category and Claim Status Codes Update

Updates, as needed, the Claim Status and Claim Status Category Codes for electronically submitted health care claims status requests and responses to explain the status of submitted claim(s).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10132.pdf

Enforcement of the Partial Hospitalization Program (PHP) 20 Hours per Week Billing Requirement - Rescinded

MLN Matters Article SE1307 was rescinded on August 18, 2017.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1607.pdf

Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program – Revision

Revision on August 23, 2017 about system changes to identify the QMB status and exemption from Medicare cost sharing, ways to promote compliance with QMB billing rules, and reminder on Medicare bad debt.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1128.pdf

Proposed Rule- Medicare Program; Cancellation of Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model (CMS-5524-P)

Proposal to cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model and to revise certain aspects of the Comprehensive Care for Joint Replacement (CJR) model.

https://www.federalregister.gov/documents/2017/08/17/2017-17446/medicare-program-cancellation-of-advancing-care-coordination-through-episode-payment-and-cardiac

Provider Error Rate Formula

Instructs Medicare Administrative Contractors (MACs) to include claims denied due to no response to additional documentation requests (ADRs) when calculating the provider error rate.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R738PI.pdf

IPPS FY 2018 Final Rule: Part 3 MS-DRGs

Published on Aug 22, 2017

20170822

| Recovery Auditor

| Coding

| Documentation

At least annually, DRG classifications and relative weights are adjusted to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources. This week is the third and final article in our series about the FY 2018 IPPS Final Rule. We finish by sharing several of the changes to the Medicare Severity Diagnosis-Related Group (MS-DRG) Classifications.

MDC 1: Diseases and Disorders of the Nervous System

Functional Quadriplegia

Section 1.C.18.f of the FY 2017 ICD-10-CM Official Coding Guidelines addresses coding the diagnosis of functional quadriplegia. “Functional quadriplegia (described by diagnosis code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. The condition is not associated with neurologic deficit or injury, and diagnosis code R53.2 should not be used to identify cases of neurologic quadriplegia. In addition, the Guidelines state that the diagnosis code should only be assigned if functional quadriplegia is specifically documented by a physician in the medical record, and the diagnosis of functional quadriplegia is not associated with a neurologic deficit or injury. A physician may document the diagnosis of functional quadriplegia as occurring with a variety of conditions.”

CMS received a request to reassign cases identified by diagnosis code R53.2 from MS-DRGs 052 and 053 (Spinal Disorders and injuries with and without CC/MCC, respectively). One commenter noted the ICD-10-CM code for functional quadriplegia is located in Chapter 18, Symptoms, Signs and Abnormal findings because it can be the result of a variety of underlying conditions and it is not appropriate to classify this diagnosis as a nervous system disorder. Clinical advisors agreed and CMS has finalized the assignment of code R532 (functional quadriplegia) to MS-DRGs 947 and 948 (Signs and Symptoms with MCC and without MCC, respectively).

Responsive Neurostimulator (RNS©) System

The RNS© Neurostimulator is a cranially implanted neurostimulator that is a treatment option for persons diagnosed with medically intractable epilepsy. Currently these cases are assigned to MS-DRG 023 (Craniotomy with Major Device Implant or Acute Complex Central Nervous System (CNS) Principal Diagnosis (PDX) with MCC or Chemo Implant) and MS-DRG 024 (Craniotomy with Major Devise Implant or Acute Complex CNS PDx without MCC).

For FY 2018, CMS is reassigning all cases with a principal diagnosis of epilepsy… and one of the following ICD-10-PCS code combinations capturing cases with the neurostimulator generators inserted into the skull (including cases involving the use of the RNS© neurostimulator), to MS-DRG 023, even if there is no MCC reported:

0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H00MZ (Insertion of neurostimulator lead into brain, open approach);
0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H03MZ (Insertion of neurostimulator lead into brain, percutaneous approach); and
0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H04MZ (Insertion of neurostimulator lead into brain, percutaneous endoscopic approach).

A complete list of epilepsy codes assigned to MS-DRG 023 can be found on page 38016 of the Final Rule.

The title for MS-DRG 023 is changing to “Craniotomy with Major Device Implant or Acute Complex Central Nervous System (CNS) Principal Diagnosis (PDX) with MCC or Chemotherapy Implant or Epilepsy with Neurostimulator” to reflect the modifications to MS-DRG assignments.

Precerebral Occlusion or Transient Ischemic Attack with Thrombolytic

“At the onset of stroke symptoms, tPA must be given within 3 hours (or up to 4.5 hours for certain eligible patients) in an attempt to dissolve a clot and improve blood flow to the specific area affected in the brain. If, upon receiving the tPA, the stroke symptoms completely resolve within 24 hours and imaging studies (if performed) are negative, the patient has suffered what is clinically defined as a transient ischemic attack, not a stroke.”

For FY 2018, ICD-10-CM diagnosis codes assigned to MS-DRGs 067, 068, and 069 will be added to the GROUPER logic for MS-DRGs 061, 062 and 063 when sequenced as principal diagnosis and reported with an ICD-10-PCS code describing use of a thrombolytic agent (for example, tPA). The title of MS-DRGs 061, 062 and 063 are changing to “Ischemic Stroke, Precerebral Occlusion or Transient Ischemia with Thrombolytic Agent with MCC, with CC and without CC/MCC” respectively, and the title of MS-DRG 069 is changing to “Transient Ischemia without Thrombolytic.”

MDC 2: Diseases and Disorders of the Eye

Swallowing Eye Drops (Tetrahydrozoline)

CMS finalized moving the following four diagnosis codes describing swallowing eye drops:

5X1A (Poisoning by ophthalmological drugs and preparations, accidental (unintentional), initial encounter);
5X2A (Poisoning by ophthalmological drugs and preparations, intentional self-harm, initial encounter);
5X3A (Poisoning by ophthalmological drugs and preparations, assault, initial encounter); and
5X4A (Poisoning by ophthalmological drugs and preparations, undetermined, initial encounter).

These codes will move from MS-DRGs 124 and 125 (Other Disorders of the Eye with and without MCC, respectively) to MS- DRGs 917 and 918 (Poisoning and Toxic Effects of Drugs with and without MCC, respectively).

MDC 5: Diseases and Disorders of the Circulatory System

Percutaneous Cardiovascular Procedures and Insertion of a Radioactive Element

Currently the following six procedure codes are included in MS-DRG 246 (Percutaneous Cardiovascular Procedures with Drug-Eluting Stent with MCC or 4+ Vessels or Stents), MS-DRG 247 (Percutaneous Cardiovascular Procedures with Drug-Eluting Stent without MCC), MS-DRG 248 (Percutaneous Cardiovascular Procedures with Non-Drug-Eluting Stent with MCC or 4= Vessels or Stents), and MS-DRG and 249 (Percutaneous Cardiovascular Procedures with Non-Drug-Eluting Stent without MCC):

WHC01Z: Insertion of radioactive element into mediastinum, open approach
0WHC31Z: Insertion of radioactive element into mediastinum, percutaneous approach
0WHC41Z: Insertion of radioactive element into mediastinum, percutaneous endoscopic approach
0WHD01Z: Insertion of radioactive element into pericardial cavity, open approach
0WHD31Z: Insertion of radioactive element into pericardial cavity, percutaneous approach
0WHD41Z: Insertion of radioactive element into pericardial cavity, percutaneous endoscopic approach

When any of the above procedure codes are reported without a percutaneous cardiovascular procedure code, they are assigned to MS-DRG 264 (Other Circulatory System O.R. Procedures).

“Unlike procedures involving the insertion of stents, none of the procedures described by the procedure codes listed above are performed in conjunction with a percutaneous cardiovascular procedure, and two of the six procedures described by these procedure codes (ICD-10-PCS codes 0WHC01Z and 0WHD01Z) are not performed using a percutaneous approach, but rather describe an open approach to performing the specific procedure…Furthermore, the indications for the insertion of a radioactive element typically involve a diagnosis of cancer, whereas the indications for the insertion of a coronary artery stent typically involve a diagnosis of coronary artery disease.” For FY 2018, these six “insertion of radioactive element” codes will maintain their current assignment to MS-DRG 264 and be removed from MS-DRGs 246 through 249.

MS-DRG Title Change for MS-DRGs 246 and 248

CMS finalized changing the title for MS-DRG 246 and 247 to better reflect the ICD-10-PCS terminology of “arteries” versus “vessels.” The two new MS-DRG titles will be:

MS-DRG 246: Percutaneous Cardiovascular Procedures with Drug-Eluting Stent with MCC or 4+ Arteries or Stents
MS-DRG 248: Percutaneous Cardiovascular Procedures with Non-Drug-Eluting Stent with MCC or 4+ Arteries or Stents

Percutaneous Mitral Valve Replacement Procedures

“MS-DRGs 266 and 267 were created to uniquely classify the subset of high-risk cases representing patients who undergo a cardiac valve replacement procedure performed by a percutaneous (endovascular) approach.”

Currently GROUPER logic for aortic and pulmonary valves are included in MS-DRGs 266 and 266. However, for the mitral valve, the GROUPER logic includes the procedures in the transapical, percutaneous approach.

CMS agreed with a requestor that all cardiac valve replacement procedures should be grouped within the same MS-DRG and finalized the reassignment of the following four mitral valve replacement procedures from MS-DRGs 216 through 221 (Cardiac Valve and Other Major Cardiothoracic Procedures with and without Cardiac Catheterization with MCC, with CC and without CC/MCC respectively) to MS-DRGs 266 and 267 (Endovascular Cardiac Valve Replacement with MCC and without MCC, respectively)

02RG37Z: Replacement of mitral valve with autologous tissue substitute, percutaneous approach
02RG38Z: Replacement of mitral valve with zooplastic tissue, percutaneous approach
02RG3JZ: Replacement of mitral valve with synthetic substitute, percutaneous approach
02RG3KZ: Replacement of mitral valve with nonautologous tissue substitute, percutaneous approach

Additionally, CMS finalized the assignment of the following eight new procedures codes, effective October 1, 2017, describing percutaneous and transapical, percutaneous tricuspid valve replacement procedures to MS-DRGs 266 and 267:

02RJ37H: Replacement of tricuspid valve with autologous tissue substitute, transapical, percutaneous approach.
02RJ37Z: Replacement of tricuspid valve with autologous tissue substitute, percutaneous approach.
02RJ38H: Replacement of tricuspid valve with zooplastic tissue, transapical, percutaneous approach.
02RJ38Z: Replacement of tricuspid valve with zooplastic tissue, percutaneous approach.
02RJ3JH: Replacement of tricuspid valve with synthetic substitute, transapical, percutaneous approach.
02RJ3JZ: Replacement of tricuspid valve with synthetic substitute, percutaneous approach.
02RJ3KH: Replacement of tricuspid valve with nonautologous tissue substitute, transapical, percutaneous approach.
02RJ3KZ: Replacement of tricuspid valve with nonautologous tissue substitute, percutaneous approach.

MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue

Total Ankle Replacement (TAR) Procedures

TAR procedures are currently assigned to MS-DRGs 469 and 470 (Major Joint Replacement or Reattachment of Lower Extremity with MCC and without MCC, respectively).

CMS finalized that all TAR procedures be reassigned from MS-DRG 470 to MS-DRG 469, even when there is no MCC reported noting “the claims data support the fact that these cases require more resources than other cases assigned to MS-DRG 470.”

Specific codes proposed for reassignment to MS-DRG 469 include the following:

0SRF0J9 (Replacement of right ankle joint with synthetic substitute, cemented, open approach);
0SRF0JA (Replacement of right ankle joint with synthetic substitute, uncemented, open approach);
0SRF0JZ (Replacement of right ankle joint with synthetic substitute, open approach);
0SRG0J9 (Replacement of left ankle joint with synthetic substitute, cemented, open approach);
0SRG0JA (Replacement of left ankle joint with synthetic substitute, uncemented, open approach); and
0SRG0JZ (Replacement of left ankle joint with synthetic substitute, open approach) for FY 2018.

Additionally, CMS finalized the following title changes for MS-DRG 469 and 470:

MS-DRG 469: Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity with MCC or Total Ankle Replacement; and
MS-DRG 470: Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCC.

Revision of Total Ankle Replacement

CMS noted in the Proposed Rule that they had received two requests to modify the MS-DRG assignment for revision of Total Ankle Replacement (TAR) procedures, indicating these procedures are assigned to MS-DRGs 515, 516, and 517 (Other Musculoskeletal System and Connective Tissue O.R. Procedures with MCC, with CC, and without CC/MCC respectively).

CMS Response Key Takeaways

CMS conducted an analysis of the correct coding revision and agreed with commenters that these cases are not captured with ICD-10-PCS codes with the root operation “Revision” as stated in the Proposed Rule. Instead, the revision of TAR cases are correctly coded using a combination of codes with the root operation “Removal and Replacement” as commenters suggested.
CMS has asked the American Hospital Association to provide additional information on how to capture revision of TARs in a future issue of Coding Clinic for ICD-10.
CMS noted that an error in replication for the ICD-10 MS-DRGs resulted in the revision of TAR procedures being assigned to MS-DRGs 469 and 470. This error was not noticed until commenters on the FY 2018 proposed rule pointed out that accurate coding of TARs would result in cases not being assigned to MS-DRGs 515, 516, and 517.
Since the implementation of ICD-10 MS-DRGs, revision TAR procedures have not been assigned to MS-DRGs 515,516, and 517. Therefore, there is no need to modify MS-DRG logic to reassign the procedures because correctly coded cases are assigned to MS-DRGs 469 and 470.
CMS noted that by finalizing that all TAR procedure codes be assigned to MS-DRG 469, even if there is no MCC present, for FY 2018 this will result in all revision of TAR procedures being assigned to MS-DRG 469.

Combined Anterior/Posterior Spinal Fusion

It was brought to the attention of CMS “that 7 of the 10 new ICD-10-PCS procedure codes describing fusion using a nanotextured surface interbody fusion device were not added to the appropriate GROUPER logic list for MS-DRGs 453, 454, and 455 (Combined Anterior/Posterior Spinal Fusion with MCC, with CC and without CC/MCC, respectively), effective October 1, 2016. The logic for MS-DRGs 453, 454, and 455 is comprised of two lists: an anterior spinal fusion list and a posterior spinal fusion list. Assignment to one of the combined spinal fusion MS-DRGs requires that a code from each list be reported.”

After reviewing spinal fusion codes using a nanotextured surface interbody fusion device CMS finalized the following:

Moving 7 codes describing spinal fusion using a nanotextured surface interbody fusion device from the posterior spinal fusion list to the anterior spinal fusion list in the GROUPER logic for MS-DRGS 453, 454, and 455.
Moving 149 procedures codes describing spinal fusion of the anterior column with a posterior approach from the posterior spinal fusion list to the anterior spinal fusion list in the GROUPER logic for MS-DRGs 453, 454, and 455.
Deleting 33 procedure codes describing spinal fusion of the posterior column with an interbody fusion device from MS-DRGs 453 through 460 and 471 through 473, as well as from the ICD-10-PCS classification.

Review of Procedures Codes in MS-DRGs 981 through 983, 984 through 986; and 987 through 989

Annually, CMS reviews the following cases to determine if it would be appropriate to change the procedures assigned among these MS-DRGs:

MS-DRGs 981, 982, and 983: Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively,
MS-DRGs 984, 985, and 986: Prostatic O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively; and
MS-DRGs 987, 988, and 989: Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively.

These MS-DRGs are reserved for when none of the O.R. procedures performed are related to the principal diagnosis. They are “intended to capture atypical cases, that is, those cases not occurring with sufficient frequency to represent a distinct, recognizable clinical group.”

Based on claims data review CMS found it is no longer necessary to maintain a separate set of MS-DRGs specifically for the prostatic O.R. procedures and therefore finalized the following:

Reassign procedure codes currently assigned to MS-DRGs 984 through 986 to MS-DRGs 987; and
Delete MS-DRGs 984, 985 and 986 as they would no longer be needed.

In the Final Rule, CMS encourages input from stakeholders concerning annual IPPS updates. In previous years, to be considered for the next annual proposed rule update, CMS has required that input be sent to them by December 7th of the prior year. As CMS undertakes working with ICD-10 data they note this will require additional time and are changing the deadline to request updates to MS-DRGs to November 1 of each year which provides them with 5 additional weeks for the data analysis and review process. For those interested in submitting comments and/or suggestions for FY 2019, they need to be sent by November 1, 2017, via the CMS MS_DRG Classification Change Requests Mailbox located at: MSDRGClassificationChange@cms.hhs.gov.

As stated in the opening of this article, we have shared a few key highlights from this portion of the Final Rule. MMP encourages all key stakeholders to take the time to dive a little deeper into the detail.

Beth Cobb

July Medicare Transmittals and Other Updates

Published on Jul 25, 2017

20170725

| Billing

| Coding

| Medicare Coverage

| Outpatient Services

TRANSMITTALS

The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year 2015 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long Term Care Hospitals (LTCH)

MLN Matters Number: MM10026
Related CR Release Date: June 30, 2017
Related CR Transmittal Number: R1863OTN
Related Change Request (CR) Number: CR10026
Effective Date: July 31, 2017
Implementation Date: July 31, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10026.pdf
Affects providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Informs MACs about updated data for determining the disproportionate share adjustment for Inpatient Prospective Payment System (IPPS) hospitals and the low income patient (LIP) adjustment for IRFs as well as payments as applicable for Long Term Care Hospitals (LTCH) discharges (for example, discharges paid the IPPS comparable amount under the short-stay outlier payment adjustment).

Implementing FISS Updates to Accommodate Section 603 Bipartisan Budget Act of 2015 - Phase 2

MLN Matters®Number: MM9907
Related Change Request (CR) #: CR 9907
Related CR Release Date: February 2, 2017
Effective Date: January 1, 2017
Related CR Transmittal #: R1783OTN
Implementation Date: July 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9907.pdf
Affects Hospital providers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: If a hospital claim is submitted with a service facility location that was not included on the CMS 855A enrollment form, the claim will be Returned to the Provider (RTP) until the CMS 855A enrollment form and claims processing system are updated.

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 23.3, Effective October 1, 2017

MLN Matters Number: MM10183
Related CR Release Date: July 14, 2017
Related CR Transmittal Number: R3807CP
Related Change Request (CR) Number: CR10183
Effective Date: October 1, 2017
Implementation Date: October 2, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10183.pdf
Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Informs the MACs about the update to the National Correct Coding Initiative (NCCI) procedure to procedure edits (PTP). This notice applies to Chapter 23, Section 20.9 of the Medicare Claims Processing Manual

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2017

MLN Matters Number: MM10156
Related CR Release Date: June 16, 2017
Related CR Transmittal Number: R3797CP
Related Change Request (CR) Number: CR 10156
Effective Date: October 1, 2017
Implementation Date: October 2, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10156.pdf
Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Informs MACs about the changes that will be included in the October 2017 quarterly release of the edit module for clinical diagnostic laboratory services.

Clarifying the Instructions for Amending or Correcting Entries in Medical Records

CR Release Date: July 21, 2017
CR Transmittal Number: R732PI
Change Request (CR) Number: CR 10120
Effective Date: August 22, 2017
Implementation Date: August 22, 2017
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R732PI.pdf

Summary: Clarifies the requirements for a practitioner to authenticate an alteration or revision in the medical records. The contractor shall also accept initials in instances when the author of the alteration must sign and date a revision made.

Notice of New Interest Rate for Medicare Overpayments and Underpayments -4th Qtr Notification for FY 2017

CR Release Date: July 13, 2017
CR Transmittal Number: R291FM
Change Request (CR) Number: CR 10227
Effective Date: July 18, 2017
Implementation Date: July 18, 2017
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R291FM.pdf

Summary: Medicare Regulation 42 CFR Section 405.378 provides for the charging and payment of interest on overpayments and underpayments to Medicare providers. The Department of the Treasury has notified the Department of Health and Human Services that the private consumer rate has been changed to 10.125 percent.

REVISED TRANSMITTALS

Qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System

In the article, the CR release date, transmittal number, and the Web address of CR9911 are revised. Clarifications are also made to the second paragraph of the Background section.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9911.pdf

Screening for Hepatitis B Virus (HBV) Infection

Reflects an updated Change Request (CR) 9859
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9859.pdf

Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)

Transmittals 196 and 3787, dated May 26, 2017, is being rescinded and replaced by Transmittals 199 and 3805 dated, July 11, 2017 to
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R199NCD.pdf
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3805CP.pdf

Summary: Update references in the CPM and NCD manuals and to add clarifying language. In the NCD manual, the reference to Pub 100-04, Chapter 32, and Section 68 needs to be changed to Section 69. In the CPM manual, the reference in Pub. 100-04, Chapter 32, Section 68 needs to be changed to Section 69 and clarifying language needs to be added to indicate that CMS will cover procedure code 0275T for PILD only when the procedure is performed within any other CED approved randomized and non-blinded clinical trial. All other information remains the same.

OTHER MEDICARE ANNOUNCEMENTS

Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2018

Summary: The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2018.

CMS Proposes Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Changes for 2018, and Releases a Request for Information (CMS-1678-P)

Summary: The Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule (CMS-1678-P) that includes updates to the 2018 rates and quality provisions, and proposes other policy changes. CMS is proposing a number of policies that would support care delivery; reduce burdens for providers, especially in rural areas; lower beneficiary out of pocket drug costs for several drugs; enhance the patient-doctor relationship; and promote flexibility in healthcare.

Revision of Civil Money Penalty (CMP) Policies and CMP Analytic Tool

July 07, 2017
Memorandum

Summary: This policy memo replaces S&C Memo 15-16-NH. When noncompliance exists, enforcement remedies, such as civil money penalties (CMPs), are intended to promote a swift return to substantial compliance for a sustained period of time, preventing future noncompliance. To increase national consistency in imposing CMPs, the Centers for Medicare & Medicaid Services (CMS) is revising the CMP analytic tool.

Medicare Quarterly Provider Compliance Newsletter [Volume 7, Issue 4]

Summary: Educational newsletter. This quarter’s focus is on Cert Findings regarding Skilled Nursing Facility (SNF) Certification and Re-certification and OIG Findings regarding Studies of Hospital Billings of use of Modifier 59 on Heart Biopsy Claims and Procedure Coding for Ventilation Support Claims

ICD-10-PCS Procedure Codes Re-Designated as Non-O.R.

Published on May 23, 2017

20170523

| Coding

| Documentation

In the Acute Care Hospital Inpatient setting, discharges are assigned to one Medicare Severity Diagnosis-Related Group (MS-DRGs) for the entire hospitalization. The MS-DRG System groups together similar clinical conditions and the procedures furnished during a hospitalization.

Principal Diagnoses, MCCs (Major Complications/Comorbidities), CCs (Complications/Comorbidities) and Procedures may all impact MS-DRG assignment. Notice I did not say will impact MS-DRG assignment. This is because there are specific MCCs, CCs and O.R. Procedures designated by CMS that will impact MS-DRG assignment and other secondary diagnoses and Non-O.R. designated procedures that won’t.

With the October 1, 2015 ICD-10-CM/PCS implementation, several new O.R. Procedure Codes impacting MS-DRG assignment had Coding Professionals and CDI Specialists questioning if the resources to perform the procedures truly supported the O.R. Procedure designation. CMS soon realized this too and included proposals in the FY 2017 IPPS Proposed Rule for consideration to re-designate certain ICD-10-PCS procedures codes from O.R. Procedures to Non-O.R. Procedures.

CMS asked and the provider community responded. In fact, CMS received over 800 recommendations and were unable to fully evaluate and finalize recommendations for release in the 2017 IPPS Final Rule.

Fast forward to the April 2017 release of the FY 2018 IPPS Proposed Rule. This year CMS is proposing to re-designate over 800 current O.R. Procedures as Non-O.R. Procedures. Specific code groups being proposed “generally would not require the resources of an operating room and can be performed at the bedside.”

For those interested in reading the detail, this discussion can be found on pages 58 through 69 of the Proposed Rule pdf document. For those that prefer the highlights, keep reading to find the Code Groups being proposed, the volume of codes being proposed for re-designation by Major Diagnostic Category (MDC), and to begin to understand the potential impact if the proposals are finalized.

Code Groups

First let’s take a look at the code groups remembering that what is being proposed are procedures that in general do not require the resources of an O.R. room and can be performed at the bedside. The following table details the number of ICD-10-PCS codes by code group and a description of the code group.

Number of Codes Proposed for Re-designation to Non-O.R. Procedures
# of Codes	Code Group	Description
135	Percutaneous/Diagnostic Drainage	Procedures involving percutaneous diagnostic & therapeutic drainage of central nervous system, vascular & other body sites.
28	Percutaneous Insertion of Intraluminal or Monitoring Device	Procedures involving the percutaneous insertion of intraluminal & monitoring devices into central nervous system & other cardiovascular body parts.
22	Percutaneous Removal of Drainage, Infusion, Intraluminal or Monitoring Device	Procedures involving removal of drainage, infusion, intraluminal and monitoring devices from central nervous system & other vascular body parts.
4	External Removal of Cardiac or Neurostimulator Lead	Procedures involving the external removal of cardiac leads from the heart & neurostimulator leads from central nervous system body parts.
28	Percutaneous Revision of Drainage, Infusion, Intraluminal or Monitoring Device	Procedures involving the percutaneous revision of drainage, infusion, intraluminal & monitoring devices for vascular & heart & great vessel body parts.
2	Percutaneous Destruction	Procedures involving the percutaneous destruction of retina body parts.
20	External/Diagnostic Drainage	Procedures involving external drainage for structures of the eye.
4	External Extirpation	Procedures involving external extirpation of matter from eye structures.
3	External Removal of Radioactive Element or Synthetic Substitute	Procedures involving the external removal of radioactive or synthetic substitutes from the eye.
8	Endoscopic/Transorifice Diagnostic Drainage	Procedures involving endoscopic/transorifice (via natural or artificial opening) drainage of ear structures.
4	External Release	Procedures involving the external release of ear structures.
3	External Repair	Procedures involving the external repair of body parts generally not requiring resources of an O.R. room & can be performed at the bedside.
8	Endoscopic/Transorifice Destruction	Procedures involving the endoscopic/transorifice destruction of respiratory system body parts.
40	Endoscopic/Transorifice Drainage	Procedures involving endoscopic/transorifice (via natural or artificial opening) drainage of respiratory system body parts.
9	Endoscopic/Transorifice Extirpation	Procedures involving endoscopic/transorifice extirpation of matter from respiratory system body parts.
16	Endoscopic/Transorifice Fragmentation	Procedures involving endoscopic/transorifice fragmentation of respiratory system body parts.
2	Endoscopic/Transorifice Insertion of Intraluminal Device	Procedures involving an endoscopic/transorifice (via natural or artificial opening) insertion of intraluminal devices into respiratory system body parts.
2	Endoscopic/Transorifice Removal of Radioactive Element	Procedures involving the endoscopic/transorifice removal of radioactive elements from respiratory system body parts.
18	Endoscopic/Transorifice Revision of Drainage, Infusion, Intraluminal or Monitoring Device	Procedures involving the revision of drainage, infusion, intraluminal, or monitoring devices from respiratory system body parts.
1	Endoscopic/Transorifice Excision	Procedure involving endoscopic/transorifice (via natural or artificial opening) excision of the digestive system body parts.
2	Endoscopic/Transorifice Insertion	Procedures involving the endoscopic/transorifice (via natural or artificial opening) insertion of intraluminal device into the stomach.
6	Endoscopic/Transorifice Removal	Procedures involving endoscopic/transorifice (via natural or artificial opening) removal of feeding devices.
2	External Reposition	Procedures involving external reposition of gastrointestinal body parts.
8	Endoscopic/Transorifice Drainage	Procedures involving endoscopic/transorifice (via natural or artificial opening) drainage of hepatobiliary system & pancreatic body parts.
2	Endoscopic/Transorifice Fragmentation	Procedures involving endoscopic/transorifice (via natural or artificial opening) fragmentation of hepatobiliary system and pancreatic body parts.
3	Percutaneous Alteration	Procedures involving percutaneous alteration of the breast.
41	External Division & Excision of Skin	Procedures involving external division & excision of the skin for body parts.
3	Percutaneous Supplement	Procedures involving percutaneous supplement of the breast with synthetic substitute.
25	Open Drainage	Procedures involving open drainage of subcutaneous tissue and fascia body parts.
2	Percutaneous Drainage	Procedures involving percutaneous drainage of subcutaneous tissue and fascia body parts.
22	Percutaneous Extraction	Procedures involving percutaneous extraction of subcutaneous tissue and fascia body parts.
44	Percutaneous & Open Repair	Procedures involving percutaneous & open repair of subcutaneous tissue & fascia body parts.
28	External Release	Procedures involving external release of bursa & ligament body parts.
135	External Repair	Procedures involving external repair of various bones & joints.
14	External Reposition	Procedures involving external reposition of various bones.
8	Endoscopic/Transorifice Dilation	Procedure involving endoscopic/transorifice (via natural or artificial opening) dilation of urinary system body parts.
3	External/Transorifice Repair	Procedures involving external & transorifice (via natural or artificial opening) repair of the vagina body part.
20	Percutaneous Transfusion	Procedures involving percutaneous transfusion of bone marrow & stem cells
51	External/Percutaneous/Transorifice Introduction	Procedures involving external, percutaneous & transorifice (via natural or artificial opening) introduction of substances.
15	Percutaneous/Diagnostic & Endoscopic/Transorifice Irrigation, Measurement & Monitoring	Procedures involving percutaneous/diagnostic & endoscopic/transorifice (via natural or artificial opening) irrigation, measurement & monitoring of structure, pressures & flow.
6	Imaging	Procedures involving imaging with contrast of hepatobiliary system body parts
5	Prosthetics	Procedures involving the fitting & use of prosthetics & assistive devices.
1	External Repair of Hymen	CMS received a comment noting when reported with a maternal delivery claim this code would sequence to a Non-Extensive O.R. Procedure Unrelated to Principal Diagnosis MS-DRG
3	Revision of Neurostimulator Generators	Re-classify to Non-O.R. Procedures that affect assignment for MS-DRGs 252, 253 and 254.
55	Non-O.R. Procedures in MDC 17: Myeloproliferative Diseases & Disorders & Poorly Differentiated Neoplasms	55 codes in surgical DRGs in MDC 17 not generally requiring greater intensity of service. Proposal to remove codes from the logic for MS-DRGs 823, 824, 825, 829 and 830.
Source: 2018 IPPS Proposed Rule

Potential Impact of ICD-10-PCS Code Re-Designation While I agree with what is being proposed, it immediately made me wonder just how many of these codes have been driving MS-DRG assignment to a Surgical MS-DRG. For answers, as I so often do, I turned to our sister company RealTime Medicare Data (RTMD) to “crunch the numbers.” At the Medicare Administrative Contractor (MAC) level, I analyzed paid claims data for Calendar Year (CY) 2016 for the Jurisdiction J MAC that adjudicates claims for Alabama, Georgia and Tennessee. At this level the numbers “feel significant.” The following table highlights the volume of claims, total charges and actual amount paid to Providers by MDC.

Jurisdiction J: Analysis of CY 2016 Claims Data for MS-DRGs billed with an O.R. Principal Procedure Proposed for Re-designation as Non-O.R. Procedure
MDC	MDC Description	Claims Volume	Total Charges	Actual Amount Paid
1	Diseases & Disorders of Nervous System	183	$15,944,250.25	$3,805,971.50
2	Diseases & Disorders of the Eye	2	$125,626.87	$26,342.95
3	Diseases & Disorders of Ear, Nose, Mouth & Throat	14	$459,895.34	$165,314.43
4	Diseases & Disorders of the Respiratory System	645	$58,788,180.68	$12,709,622.78
5	Diseases & Disorders of the Circulatory System	543	$36,349,592.30	$9,424,610.51
6	Diseases & Disorders of the Digestive System	150	$12,865,336.78	$2,729,084.20
7	Diseases & Disorders of the Hepatobiliary System & Pancreas	27	$2,835,334.02	$573,882.69
8	Diseases & Disorders of the Musculoskeletal System & Connective Tissue	246	$16,144,154.87	$4,009,804.65
9	Diseases & Disorders of the Skin, Subcutaneous Tissue & Breast	640	$23,696,743.05	$5,978,843.07
10	Endocrine, Nutritional & Metabolic Diseases & Disorders	96	$5,324,272.95	$1,206,764.54
11	Diseases & Disorders of the Kidney & Urinary Tract	92	$5,939,431.60	$1,583,534.20
12	Diseases & Disorders of the Male Reproductive System	15	$759,175.78	$136,602.15
13	Diseases & Disorders of the Female Reproductive System	72	$2,716,702.78	$435,544.38
14	Pregnancy, Childbirth & the Puerperium	4	$74,852.30	$42,681.90
16	Diseases & Disorders of the Blood & Blood Forming Organs & Immunological Disorders	29	$3,463,535.41	$765,168.66
17	Myeloproliferative Diseases & Disorders & Poorly Differentiated Neoplasms	7	$1,308,190.78	$302,282.44
18	Infectious & Parasitic Diseases, Systemic & Unspecified Sites	552	$51,655,515.59	$12,445,041.21
19	Mental Diseases & Disorders	18	$1,711,514.14	$318,473.26
21	Injuries, Poisonings & Toxic Effects of Drugs	161	$9,371,259.62	$2,226,445.08
22	Burns	17	$2,799,766.48	$707,332.77
23	Factors Influencing Health Status & Other Contacts with Health Services	24	$1,524,568.97	$450,753.48
24	Multiple Significant Trauma	10	$682,308.90	$274,780.75
25	HIV Infections	7	$1,217,432.80	$246,849.07
Pre-MDCs		414	$55,659,239.06	$13,152,598.75
Overall:		3,968	$311,416,881.30	$73,718,329.42
Source: RealTime Medicare Data (RTMD) Calendar Year 2016 Inpatient Claims Data for AL, GA & TN

‍

Key Takeaway from the Data:

For Calendar Year 2016, 3,968 claims were paid to Providers in Alabama, Georgia, and Tennessee combined in the amount of $73,718,329.42.
MDC 4: Diseases and Disorders of the Respiratory System had the highest volume of claims paid at 645.
MDC 9: Diseases and Disorders of the Skin, Subcutaneous Tissue & Breast came in a close second at 640 claims paid.
Pre-MDCs, while not the highest volume of claims, resulted in the highest actual claims payment at $13,152,598.75.

MS-DRG Shift from Surgical to Medical

Yes, these 800+ ICD-10-PCS codes resulted in assignment to a surgical MS-DRG for almost 4,000 claims and several million dollars. However, it is important to remember without the ICD-10-PCS code designation, your hospital would still receive reimbursement for the Medical Principal Diagnosis. The Relative Weights of the Surgical MS-DRGs assigned ranged from 0.5865 all the way to 17.95. From this it is reasonable to assume the shift in payment will also vary widely.

In order to put this into context, I have provided the following examples of the financial impact when there is an MS-DRG shift from a Surgical MS-DRGs to a Medical MS-DRG:

Patient A
Dates of Service: 3/29/2016 – 4/19/2016
Principal Procedure Code: 06H03DZ Insertion of Intraluminal Device into Inferior Vena Cava, Percutaneous Approach
Principal Medical Diagnosis Code: A4195 Other Gram-negative sepsis
MS-DRG Assigned 03: ECMO or Tracheostomy with Mechanical Ventilation >96 Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. Procedure
Relative Weight: 17.657
CMS FY 2016 National Average Reimbursement $95,944.77.
Without any additional procedure to drive MS-DRG assignment and without an MCC, in this scenario the MS-DRG would be reassigned to:
MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC
Relative Weight: 1.0427
CMS FY 2016 National Average Reimbursement $5,665.86
Patient B
Dates of Service: 5/3/2016 – 5/13/2016
Principal Procedure Code: 30233Y0 Transfusion of Autologous Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach
Principal Medical Diagnosis Code: R112 Nausea with vomiting, unspecified
MS-DRG Assigned: 016 Autologous Bone Marrow Transplant with CC/MCC
Relative Weight: 6.1746
CMS FY 2016 National Average Reimbursement: $33,551.79
Without any additional procedures to drive MS-DRG assignment, in this scenario with an MCC, the MS-DRG would be reassigned to:
MS-DRG 391: Esophagitis, Gastroenteritis & Miscellaneous Digestive Orders with MCC
Relative Weight: 1.1925
CMS FY 2016 National Average Reimbursement: $6,479.85
Patient C
Dates of Service: 7/18/2016 – 7/23/2017
Principal Procedure Code: 0HBFXZZ Excision of Right Hand Skin, External Approach
Principal Medical Diagnosis Code: L03011 Cellulitis of Right Finger
MS-DRG Assigned: 572 Skin Debridement without CC/MCC
Relative Weight 1.0391
CM FY 2016 National Average Reimbursement: $5,646.30
Without and additional procedures to drive MS-DRG assignment, in this scenario, the MS-DRG would be reassigned to:
MS-DRG 603: Cellulitis without MCC
Relative Weight: 0.8429
CMS FY 2016 National Average Reimbursement: $4,580.18

MMP strongly encourages key stakeholders at your facility take the time to review the proposed rule and submit comments. CMS is accepting comments through 5 p.m. EDT on June 13, 2017.

Resource:

2018 IPPS Proposed Rule published in the Federal Register: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Proposed-Rule-Home-Page.html

Beth Cobb

Physician Advisor and the Controversy of a Patient's Final Diagnosis

Published on Apr 04, 2017

20170404

| Coding

Let me start off by saying, there is no denying the importance and need of a physician advisor, especially in this day and time of Medicare compliance audits. Years ago the hiring of a physician advisor seemed more or less optional but as time moves forward the physician advisor’s role has become an integral component within the Clinical Documentation Improvement (CDI) program.

Physician advisors are a great asset to a hospital and they serve as a much needed bridge and advocate between the provider (attending physician) and CDI, coders and HIM. They play a very important role as an inside consultant working as an influential diplomat in accomplishing goals by using their clinical knowledge, their understanding of quality standards & metrics and the importance of coded data to a hospitals present and future reimbursement.

With all this being noted, there are also limits to a physician advisor’s responsibilities. As a licensed physician, they cannot change or add additional documentation in a patient’s record in which they themselves have not provided direct medical care. They also cannot use their own opinion to override a diagnosis provided by the provider. If the physician advisor’s opinion differs from that of the provider, then he/she must contact that particular physician and follow the industry standard guideline for communication (e.g., speaking one on one or querying).

At the end of the day when all is said and done; the provider that has clinically evaluated the patient, developed a therapeutic treatment plan and/or procedure(s) and established a diagnosis is the one responsible for that diagnosis both legally and morally. A provider could possibly deny responsibility should anyone, physician advisor included, override their professionally established diagnosis. Can you imagine the legal ramifications that could bring on the hospital/facility?

There will definitely be times when a physician advisor, CDI and/or coder may feel that clinical indications currently listed in the record need to be specified further in order to give greater support. Of course in these situations a query should be sent. The 2008 AHIMA practice brief titled, “Managing an Effective Query Process” noted the following guideline:

“Codes assigned to clinical data should be clearly and consistently supported by provider documentation. Providers often make clinical diagnoses that may not appear to be consistent with test results. For example, the provider may make a clinical determination that the patient has pneumonia when the results of the chest x-ray may be negative. Queries should not be used to question a provider’s clinical judgement, but rather to clarify documentation when it fails to meet any of the five criteria listed above – legibility, completeness, clarity, consistency, or precision… In situations where the provider’s documented diagnosis does not appear to be supported by clinical findings, a healthcare entity’s policies can provide guidance on a process for addressing the issue without querying the attending physician.”

There are no guidelines which allow an override process when it comes to the attending provider and a patient’s diagnosis. Per Section I.A.19 of the ICD-10-CM Official Guidelines for Coding and Reporting, “The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

Greater detail on the reporting of a diagnosis code is found in Coding Clinic 4th Qtr. 2016 page 147. “Coding must be based on provider documentation. This guideline is not a new concept, although it had not been explicitly included in the official coding guidelines until now. Coding Clinic and the official coding guidelines have always stated that code assignment should be based on provider documentation. As has been repeatedly stated in Coding Clinic over the years, diagnosing a patient's condition is solely the responsibility of the provider. Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis, can "diagnose" the patient. As also stated in Coding Clinic in the past, clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider's clinical judgment, or eliminate the need for provider documentation regarding the clinical significance of a patient's medical condition.”

The physician advisor should help to monitor a provider that may have developed a trend of establishing a diagnosis that consistently results in denials and/or penalties and puts the facility at risk for lost reimbursement. In cases such as this, the established steps should be taken to rectify the situation. It is clearly not the role of the physician advisor to establish that final diagnosis of a patient’s condition.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful

References:

Clinical Criteria and code Assignment - Coding Clinic 4th Quarter 2016 Page 147 – Oct. 1, 2016

Section I.A.19 of the ICD-10-CM Official Guidelines for Coding and Reporting – October 1, 2016

The Physician Advisor’s Guide to Clinical Documentation Improvement - 2014
https://store.healthleadersmedia.com/aitdownloadablefiles/download/aitfile/aitfile_id/1720.pdf

ICD-10 Monitor: Controversial – Attending Physicians Denying Responsibility? – Nov. 28, 2016
https://www.icd10monitor.com/controversial-attending-physicians-denying-responsibility

Defining the Role of a Physician Advisor - August 15, 2007
http://www.hcpro.com/REV-75168-5354/Defining-the-role-of-a-physician-advisor.html

Who Makes a Good Physician Advisor and What Can They Do For You? – May 6, 2016
https://www.ahcmedia.com/articles/137835-who-makes-a-good-physician-advisor-and-what-can-they-do-for-you

The Value of a Physician Advisor – December 1, 2014
http://www.providentedge.com/the-value-of-a-physician-advisor/

Taking Coding to the Next Level through Clinical Validation
http://library.ahima.org/doc?oid=300246#.WM_f-2Y2yUk

2013 ACDIS/AHIMA guidance titled “Guidelines for Achieving a Compliant Query Practice” – April 2013
http://www.hcpro.com/content/290814.pdf

Ask ACDIS: Escalation Policies and Clinical Validation Queries - September 1, 2015
http://www.hcpro.com/HOM-320974-5728/Ask-ACDIS-Escalation-policies-and-clinical-validation-queries.html

Marsha Winslett

New Evaluation Codes for Occupational Therapy

Published on Apr 04, 2017

20170404

| AL Medicaid

| Coding

| Outpatient Services

April is National Occupational Therapy month. We at MMP want to acknowledge and thank occupational therapists for their dedication and hard work. According to the American Occupational Therapy Association (AOTA), occupational therapy (OT) is “a vitally important profession that helps people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities.”

There are always new and continuing challenges for OTs in addition to those associated with patient care and 2017 is no different. One of the biggest changes for 2017 is new CPT codes for evaluative services – significantly going from one initial evaluation code to three codes based on the level of complexity of the evaluation. The new codes levels are based on patient history/occupational profile, assessment, and decision making – sounds straight-forward, but a lot more complicated than it appears. First, be aware that all three components must be considered in determining the complexity level of the evaluation as low, moderate, or high. In order to move to a higher level of evaluation all three components must be of the higher level.

Good News

Before we examine the components of the new evaluation codes, there is good news. When the initial 2017 payments rates for the new evaluation/reevaluation codes were released, OTs were shocked to see a decrease in payment rates from last year. CMS has reported there was a technical, computational error in determining the Practice Expense (PE) relative value unit (RVU) for the OT Evaluation and Reevaluation codes. In MLN Matters Article MM9977 April Updates, CMS published new higher weighted PE RVUs that will be retroactive to January 1, 2017 and will result in higher payment rates for the OT evaluation codes once rate corrections are made.

Patient History/Occupational Profile

In a low level evaluation (CPT 97165), the occupational profile and medical/therapy history include a brief history with review of medical and/or therapy records relating to the presenting problem.
Moderate level (CPT 97166) includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.
High level (CPT 97167) includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.

The key words associated with each level respectively are “brief,” “expanded,” and “extensive.”

The OT considers the patient’s medical and therapy history – what was their prior level of function, their current problem, their goals for treatment – to determine how much review of history is needed to assess the patient and develop a plan of care. These same elements are considered in deciding how complex of an occupational profile is required. Such a profile examines the patient’s occupational history and experiences, patterns of daily living, interests, values, and needs.

Assessment

The assessment level is based on the number of performance deficits identified related to physical, cognitive, or psychosocial skills, and that result in activity limitations and/or participation restrictions. Low complexity (97165) is 1-3 performance deficits, moderate complexity (97166) is 3-5 deficits, and high complexity (97167) is 5 or more deficits.

Performance deficits (activity limitations and/or participation restrictions) are usually identified using standardized assessments. Per the CPT instructions, performance deficits refer to the inability to complete activities due to the lack of skills in one or more of the categories below:

Physical skills are body structures and functions such as balance, mobility, strength, endurance, fine or gross motor coordination, sensation, dexterity, etc. (AOTA description - motor skills)
Cognitive skills refer to the ability to attend, perceive, think, understand, problem solve, mentally sequence, learn, and remember. Appropriate cognitive skills allow a person to organize occupational performance in a timely and safe manner. (AOTA description - process skills)
Psychosocial skills are necessary to successfully and appropriately participate in everyday tasks and social situations. These are influenced by a person’s interpersonal interactions, habits, behaviors, coping strategies, and environmental adaptations. (AOTA description - social interaction skills)

Decision Making

Now comes the hard part where the OT earns their keep, so to speak – taking all of the information from the patient’s history, an analysis of the occupational profile, and the identified performance deficits from the assessment to determine the goals for treatment and develop a plan of care to address those goals. There are a number of factors to consider in the decision making process for occupational therapy.

Complexity – Overall, how complex is the therapist’s clinical decision making – low complexity (97165), moderate analytic complexity (97166), or high analytic complexity (97167)?
Assessment data analysis – Was the assessment problem-focused (97165); detailed (97166); or comprehensive (97197)?
Number of treatment options – Based on the patient’s condition and goals, how many treatment options does the OT consider – only a limited number (97165), several treatment options (97166), or multiple treatment options (97167)?
Co-morbidities – Does the patient have co-morbidities that affect occupational performance? – No (97165), may have some (97166), or definitely has co-morbidities (97167).
Assessment modification/assistance – Does the therapist have to provide assistance or make modifications to the assessment(s) to enable the patient to complete the evaluation? Examples could be verbal or physical modifications to directions, task complexity, environment, time, etc. No modifications required (97165), minimal to moderate modification necessary (97166), significant modification required (97167).

Time

You may have noticed that I did not list time as one of the factors to be considered in selecting the evaluation level. That is because time is not a determining factor in selection of the appropriate code. The complexity of the evaluation as described above determines which level of code is selected. Also, the evaluation codes are not time-based codes; one unit of an evaluation code is submitted regardless of the amount of time spent on the evaluation.

Although time is not a factor in determining the code level, the CPT code language provides typical face-to-face times with the patient and/or family for the various code levels. These times are a general guideline about how long each of the levels of evaluation codes might take and to show that higher complexity evaluations take more time than lower complexity evaluations. For OT evaluations the typical times are 30 minutes for low complexity (97165), 45 minutes for moderate complexity (97166) and 60 minutes for high complexity (97167).

Reevaluation Code

The new reevaluation code, CPT 97168, replaces the old code and requires the following components:

An assessment of changes in patient functional or medical status with revised plan of care;
An update to the initial occupational profile to reflect changes in condition or environment that affect future intervention and/or goals; and
A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan or care is required.

Typical time for a reevaluation is 30 minutes of face-to-face time with the patient and/or family.

According to an AOTA article about the new occupational therapy evaluation codes:

“The new descriptions in CPT® set the stage for promoting optimal occupational therapy practice. By conducting a profile, doing standardized and other tests and measures, and showing the breadth of concerns occupational therapy considers, we promote distinct value. The evaluation process can communicate to others the full scope of occupational therapy practice. The codes can be a tool to promote distinct value.”

Occupational Therapy Month is a good time to appreciate the value of OT.

Debbie Rubio

February Medicare Transmittals and Other Updates

Published on Feb 28, 2017

20170228

| Recovery Auditor

| Coding

| Outpatient Services

TRANSMITTALS

Medicare Outpatient Observation Notice (MOON) Instructions

MLN Matters® Number: MM9935 Revised
Related Change Request (CR) #: CR 9935
Related CR Release Date: January 27, 2017
Effective Date: February 21, 2017
Related CR Transmittal #: R3698CP
Implementation Date: February 21, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9935.pdf
Affects hospitals, including Critical Access Hospitals (CAHs) submitting claims to Medicare Administrative Contractors (MACs) for outpatient observation services provided to Medicare beneficiaries.

Summary: Updates Chapter 30 of the “Medicare Claims Processing Manual” to include the Medicare Outpatient Observation Notice (MOON), CMS-10611, and related instructions. Providers should use the MOON to inform Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or a Critical Access Hospital (CAH). The instructions included in Chapter 30 provide guidance for proper issuance of the MOON.

ICD-10 Coding Revisions to National Coverage Determination (NCDs)

MLN Matters® Number:MM9861
Related Change Request (CR) #: CR 9861
Related CR Release Date: February 3, 2017
Effective Date: October 1, 2016 - Unless otherwise noted in individual requirements
Related CR Transmittal #: R1792OTN
Implementation Date: March 3, 2017 - MAC local systems; April 3, 2017 - FISS, MCS, CWF Shared systems
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9861.pdf
Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: The 10th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

Revisions to State Operations Manual (SOM), Appendix C-Survey Procedures and Interpretive Guidelines for Laboratories and Laboratory Services

Transmittal # R166SOMA
Issue Date: February 3, 2017
Implementation Date: March 3, 2017
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R166SOMA.pdf

Implementation of New Influenza Virus Vaccine Code

MLN Matters® Number: MM9876
Related Change Request (CR) #: CR 9876
Related CR Release Date: February 3, 2017
Effective Date: July 1, 2017
Related CR Transmittal #: R3711CP
Implementation Date: July 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9876.pdf
Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Provides instructions for payment and edits for the common working file (CWF) to include influenza virus vaccine code 90682 (Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use) for claims with dates of service on or after July 1, 2017.

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 23.1, Effective April 1, 2017

MLN Matters® Number: MM9970
Related Change Request (CR) #: CR 9970
Related CR Release Date: February 3, 2017
Effective Date: April 1, 2017
Related CR Transmittal #: R3708CP
Implementation Date: April 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9970.pdf
Affects physicians, other providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: The latest package of Correct Coding Initiative (CCI) Procedure to Procedure (PTP) edits, Version 23.1, effective April 1, 2017. The National Correct Coding Initiative (NCCI) developed by the Centers for Medicare & Medicaid (CMS) helps promote national correct coding methodologies and controls improper coding.

Qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System

MLN Matters® Number: MM9911
Related Change Request (CR) #: CR 9911
Effective Date: for claims processed on or after October 2, 2017
Related CR Release Date: February 3, 2017
Related CR Transmittal #: R3715CP
Implementation Date: October 2, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9911.pdf
Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs and Durable Medical Equipment MACs, for services provided to Medicare beneficiaries.

Summary: Modifies the Medicare claims processing systems to help providers more readily identify the Qualified Medicare Beneficiary (QMB) status of each patient and to support providers’ ability to follow QMB billing requirements.

New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs)

MLN Matters® Number: MM9893
Related Change Request (CR) #: CR 9893
Related CR Release Date: February 3, 2017
Effective Date: October 1, 2017
Related CR Transmittal #: R1787OTN
Implementation Date: October 2, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9893.pdf
Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: CMS will establish two (2) new set-aside processes: a Liability Insurance Medicare Set-Aside Arrangement (LMSA), and a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA). An LMSA or an NFMSA is an allocation of funds from a liability or an auto/no-fault related settlement, judgment, award, or other payment that is used to pay for an individual’s future medical and/or future prescription drug treatment expenses that would otherwise be reimbursable by Medicare.

Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens

MLN Matters® Number: MM9960
Related Change Request (CR) #: CR 9960
Related CR Release Date: February 10, 2017
Effective Date: January 1, 2017
Related CR Transmittal #: R3717CP
Implementation Date: May 12, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9960.pdf
Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat-rate basis using HCPCS code P9604 for Calendar Year (CY) 2017.

Advance Care Planning (ACP) Implementation for Outpatient Prospective Payment System (OPPS) Claims

MLN Matters® Number: MM9862
Related Change Request (CR) #: CR 9862
Related CR Release Date: February 10, 2017
Effective Date: January 1, 2016
Related CR Transmittal #: R1795OTN
Implementation Date: July 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9862.pdf
Affects physicians and providers submitting claims on Type of Bill 13x to Medicare
Administrative Contractors (MACs) for Advance Care Planning (ACP) services payable under the Outpatient Prospective Payment System (OPPS).

Summary: Implements system changes necessary to process Advance Care Planning (ACP) services for OPPS claims.

ICD-10 Coding Revisions to National Coverage Determinations (NCDs)

MLN Matters® Number: MM9982
Related Change Request (CR) #: CR 9982
Effective Date: July 1, 2017 (Unless otherwise noted in individual NCDs)
Related CR Release Date: February 17, 2017
Related CR Transmittal #: R1798OTN
Implementation Date: March 20, 2017, for MAC edits and July 3, 2017, for Shared Systems
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9982.pdf
Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: The 11th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

Episode Payment Model Operations

MLN Matters® Number: MM9916
Related Change Request (CR) #: CR 9916
Related CR Release Date: February 17, 2017
Effective Date: July 1, 2017
Related CR Transmittal #: R169DEMO
Implementation Date: July 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9916.pdf
Affects physicians and acute care hospitals that submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Prepares Medicare’s claims processing systems and provides information for implementation of Episode Payment Models (EPMs)

OTHER MEDICARE ANNOUNCEMENTS

Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures

Final Rule: Federal Register, January 17, 2017
https://www.gpo.gov/fdsys/pkg/FR-2017-01-17/pdf/2016-32058.pdf

Summary: This final rule revises the procedures that the Department of Health and Human Services (HHS) follows at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, this final rule revises procedures that the Department of Health and Human Services follows at the Centers for Medicare & Medicaid Services (CMS) and the Medicare Appeals Council (Council) levels of appeal for certain matters affecting the ALJ level.

Recommendations to Providers Regarding Cyber Security

Memorandum to State Survey Agency Directors
January 13, 2017
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-17.pdf

Summary: The Centers for Medicare & Medicaid Services (CMS) is reminding providers and suppliers to keep current with best practices regarding mitigation of cyber security attacks. We have outlined resources to assist facilities in their reviews of their cyber security and IT programs.

U.S. Department of Justice: Evaluation of Corporate Compliance Programs

https://www.justice.gov/criminal-fraud/page/file/937501/download

Summary: The DOJ must evaluate corporate compliance programs in the specific context of a criminal investigation. In conducting an investigation of a corporate entity, determining whether to bring charges, and negotiating plea or other agreements, prosecutors should consider specific factors such as “the existence and effectiveness of the corporation’s pre-existing compliance program” and the corporation’s remedial efforts “to implement an effective corporate compliance program or to improve an existing one.” This document provides some important topics and sample questions that the Fraud Section (of the DOJ) has frequently found relevant in evaluating a corporate compliance program.

January Medicare Transmittals and Other Updates

Published on Jan 31, 2017

20170131

| Recovery Auditor

| Coding

| OIG

| Outpatient Services

| Patient Status

TRANSMITTALS

Calendar Year (CY) 2017 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

MLN Matters® Number: MM9909
Related Change Request (CR) #: CR 9909
Related CR Release Date: December 29, 2016
Effective Date: January 1, 2017
Related CR Transmittal #: R3687CP
Implementation Date: January 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9909.pdf
Affects clinical diagnostic laboratories submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Provides instructions for the Calendar Year (CY) 2017 clinical laboratory fee schedule, mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment. This update applies to Chapter 16, Section 20 of the “Medicare Claims Processing Manual.”

April 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

MLN Matters® Number: MM9945
Related Change Request (CR) #: CR 9945
Related CR Release Date: January 13, 2017
Effective Date: April 1, 2017
Related CR Transmittal #: R3692CP
Implementation Date: April 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9945.pdf
Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Provides the April 2017 quarterly update Average Sales Price (ASP) drug pricing files for Medicare Part B drugs.

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2017

MLN Matters® Number: MM9934
Related Change Request (CR) #: CR 9934
Related CR Release Date: January 13, 2017
Effective Date: October 1, 2016
Related CR Transmittal #: R3691CP
Implementation Date: April 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9934.pdf
Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Changes that will be included in the April 2017 quarterly release of the edit module for clinical diagnostic laboratory services.

Notice of New Interest Rate for Medicare Overpayments and Underpayments - 2nd Qtr Notification for FY 2017

Related Change Request (CR) #: CR 9978
Related CR Release Date: January 11, 2017
Effective Date: January 19, 2017
Related CR Transmittal #: R280FM
Implementation Date: January 19, 2017
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R280FM.pdf
Affects Medicare providers

Summary: Medicare Regulation 42 CFR Section 405.378 provides for the charging and payment of interest on overpayments and underpayments to Medicare providers. The Secretary of Treasury certifies an interest rate quarterly. The Medicare contractors shall implement an interest rate of 9.50 percent effective January 19, 2017 for Medicare overpayments and underpayments.

Medicare Outpatient Observation Notice (MOON) Instructions

MLN Matters® Number: MM9935
Related Change Request (CR) #: CR 9935
Related CR Release Date: January 20, 2017
Effective Date: February 21, 2017
Related CR Transmittal #: R3695CP
Implementation Date: February 21, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9935.pdf
Affects hospitals, including Critical Access Hospitals (CAHs) submitting claims to Medicare Administrative Contractors (MACs) for outpatient observation services provided to Medicare beneficiaries.

OTHER MEDICARE ANNOUNCEMENTS

January 2017 Medicare Quarterly Provider Compliance Newsletter

Guidance to address billing errors
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909313.pdf

Summary: Provides education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Fee-For-Service (FFS) Program. It includes guidance to help health care professionals address and avoid the top issues of the particular quarter. Hospital topics this quarter include facet joint injections, radiation therapy, stem cell transplants, and long-term acute care (LTAC) stays.

Final Rule: Revisions to the Office of Inspector General’s Exclusion Authorities

Federal Register, January 12, 2017
Effective: February 13, 2017
https://www.gpo.gov/fdsys/pkg/FR-2017-01-12/pdf/2016-31390.pdf

Summary: This final rule amends the regulations relating to exclusion authorities under the authority of the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS or the Department). The final rule incorporates statutory changes, early reinstatement provisions, and policy changes, and clarifies existing regulatory provisions.

Final Rule: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR)

Federal Register, January 3, 2017
Effective: February 18, 2017
https://www.federalregister.gov/documents/2017/01/03/2016-30746/medicare-program-advancing-care-coordination-through-episode-payment-models-epms-cardiac

Summary: This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-for-service beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.

December Medicare Transmittals and Other Updates

Published on Jan 02, 2017

20170102

| FAQ

| Billing

| Coding

| OIG

| Outpatient Services

TRANSMITTALS

Update to Medicare Deductible, Coinsurance and Premium Rates for 2017

MLN Matters® Number: MM9902
Related Change Request (CR) #: CR 9902
Related CR Release Date: December 2, 2016
Effective Date: January 1, 2017
Related CR Transmittal #: R103GI
Implementation Date: January 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9902.pdf
Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs and Durable Medical Equipment MACs, for services provided to Medicare beneficiaries.

Summary: The new Calendar Year (CY) 2017 Medicare deductible, coinsurance, and premium rates.

Implementing Provider File Updates and PECOS to FISS Interface Via Extract File Updates to Accommodate Section 603 Bipartisan Budget Act of 2015

MLN Matters® Number: MM9613
Related Change Request (CR) #: CR 9613
Related CR Release Date: August 5, 2016
Effective Date: January 1, 2017
Related CR Transmittal #: R1704OTN
Implementation Date: January 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9613.pdf
Affects hospitals with off-campus outpatient departments submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: All off-campus outpatient departments of a hospital provider are required to be correctly identified.

HCPCS Code Update for Preventive Services

MLN Matters® Number: MM9888
Related Change Request (CR) #: CR 9888
Related CR Release Date: December 2, 2016
Effective Date: January 1, 2017
Related CR Transmittal #: R3669CP
Implementation Date: January 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9888.pdf
Affects physicians and providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Effective for dates of service on and after January 1, 2017, CPT code 76706 replaces HCPCS code G0389. MACs will apply all editing that was applied to HCPCS code G0389 to CPT code 76706, including the waiver of deductible and coinsurance.

Update to Editing of Therapy Services to Reflect Coding Changes

MLN Matters® Number: MM9698
Related Change Request (CR) #: CR 9698
Related CR Release Date: December 1, 2016
Effective Date: January 1, 2017
Related CR Transmittal #: R3670CP
Implementation Date: April 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9698.pdf
Affects providers submitting claims to Medicare Administrative Contractors (MACs) for physical and occupational therapy services provided to Medicare beneficiaries.

Summary: Instructs the MACs to apply certain coding edits to the new Current Procedural Terminology (CPT) codes that are used to report physical and occupational therapy evaluations and re-evaluations, effective January 1, 2017.

New Revenue Code 0815 for Allogeneic Stem Cell Acquisition Services

MLN Matters® Number: MM9674
Related Change Request (CR) #: CR 9674
Related CR Release Date: July 29, 2016
Effective Date: January 1, 2017
Related CR Transmittal #: R3571CP
Implementation Date: January 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9674.pdf
Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for stem cell transplant services provided to Medicare beneficiaries.

Summary: Medicare systems will accept revenue code 0815 (Allogeneic Stem Cell Acquisition/Donor Services), recently created by the National Uniform Billing Committee (NUBC), effective January 1, 2017, when submitted on hospital claims (Types of Bill (TOB) 011x, 012x, 013x, or 085x)

Comprehensive Care for Joint Replacement (CJR) Model: Skilled Nursing Facility (SNF) 3-Day Rule Waiver

MLN Matters® Number: SE1626
Article Release Date: December 9, 2016
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1626.pdf
Affects Skilled Nursing Facilities (SNFs) submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries in the Comprehensive Care for Joint Replacement (CRJ) model. Although this article applies to SNFs, hospitals participating in the CRJ model may be interested in this information.

Summary: This article informs SNFs of the policies surrounding use of the 3-day stay waiver available for use under the CJR Model and to provide instructions on using the demonstration code 75 on applicable CJR claims submitted on or after January 1, 2017.

January 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.0

MLN Matters® Number: MM9892
Related Change Request (CR) #: CR 9892
Related CR Release Date: December 9, 2016
Effective Date: January 1, 2017
Related CR Transmittal #: R3674CP
Implementation Date: January 3, 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9892.pdf
Affects providers who submit institutional claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH+H) MACs, for services provided to Medicare beneficiaries.

Summary: Provides instructions and specifications for the Integrated Outpatient Code Editor (I/OCE) used for Outpatient Prospective Payment System (OPPS) and non-OPPS claims.

OTHER MEDICARE ANNOUNCEMENTS

FY 2015 Medicare FFS RAC Report to Congress

On December 7, CMS posted the Fiscal Year 2015 Recovery Audit Program Report to Congress. CMS has also published the related FY 2015 Recovery Audit Program Appendices.

Final Medicare Outpatient Observation Notice (MOON) (CMS-10611) Available

On December 8, CMS published a Fact Sheet regarding the release the final OMB-approved Medicare Outpatient Observation Notice (MOON) along with instructions for the form. Hospitals and critical access hospitals (CAH) must begin using the MOON no later than March 8, 2017. The Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospitals and CAHS to provide notification to individuals receiving observation services as outpatients for more than 24 hours explaining the status of the individual as an outpatient, not an inpatient, and the implications of that status.

Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements

On December 7, the OIG published a final rule in the Federal Register, amending the safe harbors to the anti-kickback statute by adding new safe harbors that protect certain payment practices and business arrangements from sanctions under the anti-kickback statute. This rule updates the existing safe harbor regulations and enhances flexibility for providers and others to engage in business arrangements to improve efficiency and access to quality care while protecting programs and patients from fraud and abuse.

Effective date: January 6, 2017

Revisions to the Office of Inspector General's Civil Monetary Penalty (CMP) Rules

On December 7, the OIG published a final rule in the Federal Register, amending its CMP rules to incorporate new CMP authorities, clarify existing authorities, and reorganize regulations on civil money penalties, assessments, and exclusions to improve readability and clarity.

Effective date: January 6, 2017

Policy Statement Regarding Gifts of Nominal Value To Medicare and Medicaid Beneficiaries

On December 7, the OIG published a Policy Statement on what it considers to be a gift of nominal value. The OIG is adjusting the previous amounts, now interpreting “nominal value” as having a retail value of no more than $15 per item or $75 in the aggregate per patient on an annual basis. As with its previous interpretation, the items may not be cash or cash equivalents.

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